residents – Page 5 – Lablogatory

The State of Graduate Medical Education and Meeting Our Nation’s Health Needs

The Institute on Medicine (IOM), the health arm of the National Academy of Sciences that provides analysis and advice on national health issues, released its report “Graduate Medical Education that Meets the Nation’s Health Needs” on July 29, 2014. Citing a lack of transparency and accountability in our current system and discordance with producing the types of physicians necessary to meet our nation’s health needs, the IOM recommended a significant overhaul of our current system of graduate medical education (GME) financing and governance over the next ten years.

Since the creation of Medicare in 1965, the federal government has provided the majority of funding for the post-graduate training of physicians with about two-thirds provided by Medicare. Originally intended as a temporary measure until a more suitable one could be found, this system has financed GME since 1965. Approximately, $15 billion ($9.7 billion from Medicare) was spent in 2012 to support GME funding.¹The IOM’s report remain recommendations unless enacted into law by Congress so aggressive lobbying efforts are expected in the forthcoming months.

In fact, there has already been quick and varied response by multiple academic medical organizations: the American Association of Medical Colleges (AAMC), the American Hospital Association (AHA), and the American Medical Association (AMA) vehemently opposed and warned that the IOM’s recommendations would destabilize our current GME infrastructure while the American Association of Family Physicians (AAFP) supported the recommendations and the American College of Physicians (ACP) falls somewhere in between. If we break down the major recommendations of the report, the reasons for each organization’s opinions become more apparent but this does not necessarily help us to determine the best way to distribute GME funding to address our future healthcare workforce needs.

Currently, there are two components to GME funding from the federal government: direct and indirect. Direct graduate medical education (DGME) funding provides for the “direct costs” of teaching hospitals for the training of residents: the salaries and benefits of residents and the faculty who supervises them, the salaries of GME administrative staff, and allocated institutional overhead costs such as electricity, space rental, and maintenance. Each hospital receives DGME funding as a per-resident amount (PRA) which is hospital specific and calculated as the DGME costs in 1984 (or 1985) divided by the number of full-time equivalent (FTE) residents per year.²This PRA is updated annually with an inflation factor and adjustment for that hospital’s resident count, limited, of course, by that hospital’s resident cap (number of allowed total residents) set by the Congressional Balanced Budget Act (BBA) of 1997.

The Medicare portion of DGME is calculated by a ratio based on the number of total in-patient days in that hospital spent by Medicare patients divided by the total number of in-patient days by all patients. There are separate PRA’s for primary care and non-primary care residents with those in primary care specialties (family medicine, general internal medicine, general pediatrics, OB/Gyn, preventative medicine, geriatric medicine, general osteopathic medicine) receiving a slightly higher amount. This is due to a congressional freeze on PRA inflation updates on non-primary care residents in 1994 and 1995.

Indirect graduate medical education (IME) funding are additional amounts paid to teaching hospitals for the “indirect costs” of being a teaching hospital. They generally incur more costs than non-teaching hospital settings due to having a sicker patient load and more “non-quantifiable” costs (eg – residents ordering extra tests).³This payment is based on a formula that takes into account the ratio between the number of interns and residents and the number of patient beds (IRB ratio) adjusted with a variable multiplier and IRB ratio caps that are set by Congress. IME funding is not weighted like DGME funding where the number of residents in their “initial residency period” (IRP) are counted as 1.0 FTE and those beyond this period as 0.5 FTE.

Of course, these funding formulas can get very complicated and are adjusted with each new Congressional legislative action on GME. But now that you have a rudimentary idea of how the federal government and Medicare fund our education as residents, let’s consider the recent IOM recommendations.

IOM Recommendation #1: aggregate GME funding should remain at current levels ($15 bil/yr) with adjustments only made for inflation over the next ten years while the recommended new GME policy is implemented; the bulk of funding ($10 bil/yr) will continue to come from Medicare.

Supporting Argument: the current GME system is unsustainable and needs to become more performance- and value-based as healthcare system evolves under healthcare reform; this would provide stable (albeit not increased) funding over this transitional period.

Opposing Argument: for years, academic medical associations and their allies have recommended an increase in GME funding stating that the rate of increase has not kept up with inflation and the expense of educating our nation’s future healthcare workforce; additionally, they have consistently recommended lifting the GME cap with little success.

IOM Recommendation #2: a new GME Policy Council should be established within the Office of Health and Human Services to provide guidance on GME issues and a new GME Center within the Centers for Medicare and Medicaid Services to administer GME funding.

Supporting Argument: more transparency and accountability is needed to make sure that our dollars are well spent to produce more efficient use and better health outcomes for patients.

Opposing Argument: more bureaucratic and inefficient “red tape” and hoops to jump through without added benefit.

IOM Recommendation #3: eliminate the DGME and IME structure and replace with an Operational Fund to finance existing GME programs; the other portion of funding would support a Transformational Fund focused on innovation and programs in needed and underserved areas.

Supporting Argument: the Operational Fund would provide for currently existing programs so as not to destabilize GME funding during the proposed transition; the Transformational Fund would be targeted to address the current geographic and subspecialty maldistribution that exists.

Opposing Argument: the geographic and subspecialty maldistribution is nothing new but merely funneling more money toward these areas will not necessarily provide more healthcare professionals in these underserved areas or specialties, especially as long as student loan financing structures remain as they are currently. This recommendation also will significantly affect the funding amounts currently received by teaching hospitals, especially urban based hospitals, where the majority of GME takes place.

IOM Recommendation #4: provide funding based on PRA only with geographic adjustments and end payments based on Medicare in-patient days, IRB ratio, and other factors currently in the funding formula. These PRA funds would be directed to the GME sponsors who are responsible for the actual educational content for the training of interns and residents rather than to teaching hospitals alone. GME sponsors can be teaching hospitals, educational institutions, community health centers, or GME consortia.⁴

Supporting Argument: funding would go directly to those responsible the actual educational content which may be a non-teaching hospital setting; studies do not support a physician workforce shortage, especially in primary care specialties.

Opposing Argument: this recommendation again will disproportionately hurt teaching hospitals as they tend to have a sicker patient load, have more patient beds, and have access to more expensive tests and treatments than more community-based and/or non-teaching hospitals; teaching hospitals often are the main settings for GME, although not necessarily the only settings, and may need to make cuts based on resident education versus operational costs of the hospital with reduction of resident slots as the outcome when a physician workforce shortage is looming.

The IOM recommendations assert to support a more targeted, performance-based investment in the training of our future healthcare workforce but do they really? Obviously, GME funding has been a hotly debated topic for the past 50 years so there are no simple solutions and everyone has their own biased opinion. Even though I have some health policy and advocacy training from my MPH and grassroots organizing background, I don’t profess to be a health policy wonk by any means so I encourage you to become more informed and decide your own opinion. And if so inclined, become more involved in health policy advocacy with the political action committees (PAC) of your affiliated academic medical organizations to lobby for your beliefs.

You can read or download an electronic copy of the report free online at: http://www.iom.edu/Reports/2014/Graduate-Medical-Education-That-Meets-the-Nations-Health-Needs.aspx

References
1. Institute on Medicine (IOM). Graduate Medical Education that Meets the Nation’s Health Needs. July 29, 2014. 256 pages.

2. American Association of Medical Colleges (AAMC). Medicare Direct Graduate Medical Education (DGME) Payments; accessed on 8/8/14 at https://www.aamc.org/advocacy/gme/71152/gme_gme0001.html

3. T Johnson and TW Coons. Recent Developments in DGME and IME Payments. American Health Lawyers Association. Updated by Laurie Garvey on 3/16/10; accessed on 8/9/14 at http://www.healthlawyers.org/Events/Programs/Materials/Documents/MM10/coons_johnson.pdf

4. E. Salsberg. IOM Graduate Medical Education Report: Better Aligning GME Funding with Healthcare Workforce Needs. Health Affairs Blog. July 31, 2014; accessed on 8/10/14 at http://healthaffairs.org/blog/2014/07/31/iom-graduate-medical-education-report-better-aligning-gme-funding-with-health-workforce-needs/

-Betty Chung, DO, MPH, MA is a third year resident physician at Rutgers – Robert Wood Johnson University Hospital in New Brunswick, NJ.

Right Test, Right Time, Right Patient: The Age of Lab Stewardship

Last week, I attended the American Association of Clinical Chemistry (AACC) conference in Chicago. I attended molecular diagnostics talks but also talks about quality improvement, the use of “big data,” and lab stewardship. I have an interest in QI as my AACC poster presentation last year was on lab interventions to reduce lab error frequency and I am also a resident on my hospital’s performance improvement committee.

So, what exactly is “big data?” It’s a word that we are hearing more often in the media these days. It’s also a term that is increasingly being used in our healthcare systems. In 2001, analyst Doug Laney defined “big data” as the “3 V’s: volume, velocity, and variety” so that’s as good a point as any to start deconstructing its meaning.

Volume refers to the enormous amounts of data that we can now generate and record due to the blazing advancement of technology. It also implies that traditional processing matters will not suffice and that innovative methods are necessary both to store and analyze this data. Velocity refers to the ability to stream data at speeds that most likely exceed our ability to analyze it completely in real-time without developing more technically advanced processors. And finally, variety refers to the multiple formats, both structured (eg – databases) and unstructured (eg – video), in which we can obtain this data.

I’m always amazed at the ability of the human mind to envision and create something new out of the void of presumed nothingness. Technology has always outstripped our ability to harness its complete potential. And the healthcare sector has usually been slower to adopt technology than other fields such as the business sector. I remember when EMR’s were first suggested and there was a lot of resistance (in med school, not that long ago, I still used paper patient charts). But now, healthcare players feel both pressure from external policy reforms and internal culture to capture and analyze “big data” in order to make patient care more cost-effective, safe, and evidence-based. And an increasing focus and scrutiny (and even compensation) on lab stewardship is a component of this movement.

I often find myself in the role of a “lab steward” during my CP calls. The majority of my calls involve discussing with, and sometimes, educating, referring physicians about the appropriateness of tests or blood products that they ordered…and not uncommonly, being perceived as the test/blood product “police” when I need to deny an order. But lab stewardship goes both ways. And these days, the amount of learning we need to keep up with to know how to be a good lab steward is prodigious, daunting, and sometimes, seemingly impossible.

So do you believe in this age of lab stewardship that it’s the job of the pathologist to collect and analyze “big [lab] data” and to employ the results to help ordering physicians to choose the right test at the right time for the right patient? Or is it a collaborative effort with ordering physicians? With patients? How do you foresee that the future practice of medicine needs to change from standards of practice currently?

-Betty Chung, DO, MPH, MA is a third year resident physician at Rutgers – Robert Wood Johnson University Hospital in New Brunswick, NJ.

First-RISE

There had been talk about it for some time. We even discussed the topic during the meeting of an ASCP committee that I served on previously. It’s the First-RISE. So, all of us senior residents know the RISE but this month, ASCP administered a slightly different test that is meant to test the new PGY-1 in their baseline knowledge compared to what is required for AP/CP training. Sometime next month, they will receive their test results just as we did our RISE scores this past spring.

I know that the First-RISE is not merely giving the RISE that we all know and love/hate to the first years…and that there are some topics on there that we just don’t see on our version of the RISE. But the idea is the same – to identify areas of strength versus weakness. Programs and residents can then take this information to devise personalized study plans or lists of topic areas to focus on more intently.

For those of you who are checklist people and/or disciplined studiers who stick to their “plans”, what is the best way to study? Do you think that First-RISE will assist program directors in helping to start off their first years on the right track? Do you think that First-RISE is meaningful?

-Betty Chung, DO, MPH, MA is a third year resident physician at Rutgers – Robert Wood Johnson University Hospital in New Brunswick, NJ.

Third Year Questions

So, half of my residency training is complete. Surprisingly, I have learned more than I thought I knew but still feel behind where I think that I should be. Initially, grossing had been most difficult for me in terms of speed and time management. But I spent 3 months at the end of my 2^nd year at our highest-volume, most-difficult surgical pathology site and only now see the benefits of my training there. Many of the lessons I learned while at that site inform how I dictate and gross my specimens now. At my new program I do not have templates to follow or surgpath fellows to advise me how to gross as I had previously. Even though my chiefs will go over the specific nuances here that may differ from how I was previously trained, I am still given more autonomy than a first year because I can apply those lessons I must have subconsciously learned.

Even so, despite all that I have learned, the thought of taking boards in approximately one year still seems far away but not far enough away that I don’t feel like the volume of information to learn is not still overwhelming. First and foremost, my thoughts wander to the prospect of starting to study for AP/CP boards (but still procrastinating as of this moment due to work and still moving in).

Then the second equally big thought on my mind is that of fellowship applications in a couple months. I just recently started researching programs. We do not have a Common Match when it comes to pathology fellowships and we are also competing for spots with non-pathology residency trained physicians for subspecialties such as dermpath, clinical microbiology, and so on. CAP members last year gave a great webinar addressing how to prepare to apply for fellowships – a handout and recorded webinar can be found at http://www.cap.org/apps/docs/pathology_residents/pdf/q_a_fellowship_webinar.pdf and http://vimeo.com/70936253, respectively.

For those who have been in this spot before, any advice how to plan my third year and address these two big beasts – studying for the boards and fellowship applications?

-Betty Chung, DO, MPH, MA is a third year resident physician at Rutgers – Robert Wood Johnson University Hospital in New Brunswick, NJ.

Flexibility within Structure: Towards Competency-Based Clinical Pathology Training

Since I previously blogged about introductory surgical pathology training, I thought that I’d switch gears and focus this week’s post on introductory CP training. Based on my limited experiences during medical school rotations and at two different residency programs, I can say that developing a targeted CP curriculum (both introductory and more advanced) to train pathology residents can be difficult. Often many of the CP services can function without a resident so clinical laboratory scientists (CLSs) may be in a quandary as to what to do with residents when we are present.

I found that I’ve had the best and most educational experiences when I spent time at a CP lab bench with a CLS who likes to teach and does it well. Lab directors should either identify techs who excel at or train their CLSs how to teach. It’s not as easy as it sounds. The technologist has to not only complete their usual daily workload but at the same time break down the important and most clinically relevant parts of what they do to residents as well as to deliver all this information in an engaging manner.

Having a written syllabus with a logical flow of requirements that builds on previously learned concepts helps to provide structure for those who need it. The syllabus should include rotation objectives, important contact information, and topics and tests necessary to cover by rotation-end. But within CP, I see more of an opportunity for us to train in a competency-based manner at our own pace and toward our individual interests. For someone like me with extensive, hands-on lab and research experience, I need less (sometimes none) of my time spent learning how tests are set up (I basically told my attendings that it wouldn’t be useful for me to watch the CLSs pipetting; by reading up quickly on an unfamiliar permutation of a test based on a concept I already know, I usually can understand it as well). Also, since I learn more by doing, letting me act as a first consult for referring physician calls about test issues really accelerated my learning because if I didn’t know about the test/issue, you can bet I did by the time I called the physician back with a response. And I also learned that a good clinical work-up is key to good care but that applies in any area of pathology that we work in.

But I understand that not everyone has experience or comfort in the lab setting. At my current program, they do two months of an introductory ‘wet lab’ rotation during their first and second years. They have competency/credentialing checklists of tasks they must perform during these rotations. The first month is spent in chemistry, special chemistry, microbiology, hematology, and blood bank becoming acquainted with the staff as well as understanding the theory and performing hands-on applications and analysis of the repertoire of tests available in each section. This is not because we will be expected to do things like a Gram stain in the future but so we have some context to understand what we will be explaining often to referring physicians when they call about a particular test. I think it also helps us to understand the time frame of task completion to help explain when we do serve as the intermediary with referring physicians. And most importantly, you get friendly with technologists who honestly really will help you a lot. Being competency-based, I was allowed the flexibility to decide my competency level (ie – I skipped the ‘perform a Gram stain’ portion of my checklist because I already had done many of these in the past). The second month is spent in more specialized areas such as molecular diagnostics, cytogenetics, advanced microbiology, and special coagulation.

Telling residents to just ‘go sit at a bench with a tech’ is not all that useful, especially if the tech is busy or not interested in or good at teaching. That’s why it is so pivotal that medical directors identify technologists who can serve in this role or do in-service trainings so they understand how to participate in resident teaching. Also, telling residents to just ‘go read up on X’ is also not the most helpful because we learn more by actively doing than just passively reading. For residents in specialties with more patient contact, they have no choice but to participate in direct patient care. At times, it seems more difficult to remember to train pathology residents to feel that same urgency they would if they had the patient in front of them and also to train them in a manner that more actively engages them, but it’s possible. It just requires more effort and thought during the curriculum design phase.

Another thing that I like here at my current program is how during July they have separate orientations to each service regardless of the fact that the first years are on intro to SP and I’m on a hybrid intro to wet lab/comprehensive CP (chemistry and microbiology) rotation with some grossing time to learn the nuances of how grossing is done at this institution. We all have to attend these AP and CP orientation sessions that are geared toward preparing us for situations we will see on call – grossing late Friday prostates for the Saturday call person, how to accession and handle a frozen, transfusion reaction calls, and so on. First years also participate in supervised CP day call with an attending to learn how to handle specific situations so that they are pros by the time they have night/weekend/holiday call as a senior resident. Here, we cover both AP/CP call at the same time as senior residents.

So, how do they teach intro to CP at your institution? How do you think is the best way to train residents during introductory CP rotations? I would love to hear your opinions.

-Betty Chung, DO, MPH, MA is a third year resident physician at Rutgers – Robert Wood Johnson University Hospital in New Brunswick, NJ.

PGY-1: First Month

So, as another July 1^st has come and passed, neophyte first years have begun their training in pathology residency training programs across the country. Many will begin with either a bootcamp-style orientation and/or an introduction to surgical pathology. Although I do have a PGY-1 friend who started with a CP rotation (and not an intro one at that).

I was fortunate to have a creative surgpath director who has an interest in different styles of medical education during my PGY-1. During the last two weeks of June, in addition to the general administrative orientation requirements, we had what we affectionately refer to as our “bootcamp.” First, we were taught proper blade/cutting technique with various food products (eg – potatoes, bratwurst) to get a feel for how to adjust our cutting technique for various specimen consistencies.

She was truly dedicated and personally went to a butcher in Chicago and picked up pig organ blocks three times for us during those two weeks. Then she and one of our two surgical fellows instructed us in the Rokitansky en bloc method of autopsy dissection after we had watched a narrated DVD that she had created from the previous year PGY-1 training sessions. We then would have to complete a fourth unsupervised pig block dissection and need to score at least a 75% in order to pass our autopsy competency exam. Those who did not pass, had to repeat the exam.

We also learned how to cut mock uteri and prostates since these are common specimens. She had molded and frozen ground turkey to simulate these organs and even added surprises like chick peas to represent leiomyomas. We practiced how to bivalve and cut the uteri for both endometrial and cervical cancers as well as how to gross prostates…although I did go through the whole year and never get one until I rotated in the fall of my second year at the VA where I got them almost daily.

Additionally, in order to learn how to cut frozen sections, we took ten sections from various organs from our pig blocks and embedded, cut, and stained frozen sections. This way we could understand how certain sections cut better than others (eg – fatty tissue is more difficult to cut), how to orient them, and how to cut them well without folding and unevenness. We were then graded on our sections for frozen section competency exam. For those who did not pass, they got some personal remediation at the cryostat with our assistant director of surgical pathology.

In the gross room, we had PAs who were good at teaching. We practiced dictating biopsies and placentas, grossing placentas, and grossing “smalls” like an appendix or gallbladder. Twice a week, we had multi-scope subspecialty sessions in dermpath, liver, renal, and neuropath since most of these types of specimens go to either our fellows or the subspecialty pathologists and our first years rarely saw them.

We initially started with a six-person, six-day schedule of frozens, grossing biopsies/smalls/bigs preview, grossing bigs, autopsy, peds path, and neuropath for 1.5 months. Our PAs usually gross our biopsies and benign smaller specimens. Then we were whittled down to a four-person, four-day schedule of frozens, preview, bigs, and autopsy with two of us taking “mandatory” vacations. The two residents that remained on SP after our five months of intro to SP were incorporate into our standard three-person, three-day schedule of frozen/grossing bigs, biopsy/smalls signout/bigs preview, and bigs signout.

At my new program, it is different because we don’t have surgpath fellows. Since we are a small program, each senior resident serves as a co-chief and one of their responsibilities is the training of the PGY-1 residents in surgpath during an initial one-month intro to SP rotation. Other senior residents on the surgpath rotation also help out with the teaching. They also give AM lectures on grossing topics in Lester’s Manual of Surgical Pathology and the specific nuances of the grossing preferences of our attendings.

As for me, I start off with a comprehensive CP rotation that combines working in both the chemistry and microbiology sections. As a PGY-1 here, they have 2 months of ‘Wet Lab’ or an intro to CP rotation. But since I am a PGY-3 transfer, I am a cross between a PGY-1 in terms of knowing how things are exactly done here and a senior resident. So this month for me combines intro to SP, Wet Lab, and the subsequent comp CP rotation that would come after Wet Lab. So, I get to gross a little (since things may be done differently here), learn about where and how things are done in the labs, and study more specialized CP topics. Since I came from a program where we rotate at four different hospitals for surgpath and can be self-directed in terms of CP, this works fine for me but still can be initially daunting in terms of trying to fit in do things the way they would like them done here.

So what do you think are the best ways to train PGY-1 residents most effectively? Should they start off with an intro to SP rotation and how should that be structured in terms of time, topic areas, and teaching of those topic areas? Or does it matter if they don’t do an intro to SP rotation and go straight into a CP rotation? And who should teach them how to gross? Let us know how things are done at your institution.

-Betty Chung, DO, MPH, MA is a third year resident physician at Rutgers – Robert Wood Johnson University Hospital in New Brunswick, NJ.

Pre-July 1st Reflections

So, July 1^st is fast approaching. It is that date each year when new residents officially start their employment. And for us senior residents, even though it may not be as momentous as our first, it still is the start of our next year of rotations and a great time for reflection. As I sit here amidst an apartment full of unpacked and half-packed boxes as I prepare to move cross-country to start my new residency, like many of the PGY-1’s, I’m reflecting on what I’ve learned, what I should’ve learned but haven’t yet, and the journey that is to come at my new residency.

First, I’d like to congratulate all the graduating seniors and fellows! You finally are on to the next phase, whether that means fellowship or employment. Most of you have put the dreaded beast of boards behind you and have reached a milestone that says you are assumed to be ready for practice with less supervision. Gone is the safety net of having your attending verify the cases but you are not completely on your own because you will still have more veteran physicians who can help you. I know that there is a lot of negativity, especially on the internet, about the current job market and decreasing reimbursement codes, but persevere. There are pathologists and advocacy organizations lobbying for our profession. It’s easy to become disillusioned but uncertainty about our future can also be looked at in a ‘glass half-full’ view – we can shape how that future evolves because nothing is set in stone as of yet. In my grassroots organizing experiences, I have seen the underdog aka ‘the little guy’ win but only when they believe that they can bring about change, mobilize and organize together with like-minded individuals, and fight for what they believe is right.

Next, I’d also like to congratulate the incoming PGY-1 again for surviving that beast we call med school. You should be very proud. I know you are probably moving cross-country now and excited about what is to come. There’s a lot to learn but it’s a great time for you. My guess is that most of you will start with an introductory surgical rotation, although I do have some friends who are starting with a CP rotation. Either way, you have probably started your orientation and/or ‘boot camp’ so you can get acquainted with your hospital’s medical record system, dictation system, and pathology basics. Although I know that some of you won’t get a boot camp and will start on rotation immediately after orientation. Don’t despair…every first year in your program with you is in the same boat. And even if some people start off ahead of others on the learning curve, what I’ve seen is that by the end of first year, most people are caught up and at the same place. The thing that may set others apart is more the effort that they put in once residency starts.

So, what is essential during residency, not just for newbies but for all of us? Here’s some surgpath advice that can also apply to other rotations:

Comfortable footwear: I can’t stress this enough, especially on rotations where you may standing for all or most of the day. I personally like Merell’s but I know that Dansko clogs are also popular – these may be expensive and sometimes not the prettiest but oh so worth every penny when your feet are not killing you at the end of the day.
Teamwork: Working long hours with high expectations where your work will impact a patient’s health can be daunting. This element really can make things easier or much harder for you. So, be observant of your peers when they are having a hard time, don’t just point out that they “are getting slammed,” offer to help (eg – gross, take pictures for a conference they need to give soon but are stuck grossing, etc) and hopefully, they will return the favor. Sharing resources with each other is also helpful. Think of the Golden Rule.
Responsibility: Pathology is one of those specialties where our hours can be reasonable and we do not have overnight call or night float. It’s also one where residents can feel as if they can leave the hospital early (especially on CP rotations) and no one will notice. But your attending will notice, especially if you are on call (eg – autopsy) and you’re not there when a task does come up. Make sure that you really take ownership of your assigned tasks. People want to know that you are reliable and keep your word (implied and explicit). And be honest…people don’t like liars who say they completed a task when they haven’t.
100% commitment: There will always be a task/rotation that we are not thrilled about (eg – performing/writing up autopsies) but remember that for each task, there is a patient attached to it. Even with autopsy, there is the patient’s family. There is always someone waiting for your diagnosis so take that responsibility seriously even though we may not feel the same urgency as those in fields who take care of the patient in person. Don’t cut corners (we all know what this means and have seen residents who do this even while we were in med school). Do things right the first time and you won’t have to repeat and waste resources.
Make a plan and set aside dedicated study time: It helps if you have a (mental) checklist (eg – read one chapter or half of one in Robbins/your book of choice, work on writing that publication, etc) of tasks and a consistent time that you devote to it each week (eg – every Sunday night), otherwise, it’s very easy to get distracted…and behind…and it will just get worse as more time passes until you re-commit to doing this. But if at first you don’t succeed, you can always try again until you perfect your discipline and time management. A few trusted sources that fit your learning style is better than having too many sources. The internet is great for this (but also make sure that the info you get is correct and from a trusted source).
Never stop reading: In addition to studying, you need to keep up on what’s current, whether via hard copy or the internet. This will help you in your daily work and also help develop yourself as a lifelong learner.
Find a good mentor and learn from them: Learn from their experience and knowledge but also develop rapport with them as these are the people who will ‘go to bat’ for you and give you recs when you apply for fellowship or a job. Be a role model and give them good things to say about you through the quality of your work and dedication. And also don’t be afraid to ask for advice or help but be humble.
Get involved: Whether it’s research, the GME council, a pathology advocacy organization, or something else, participate. It will enrich your experience and also help prepare you for when you are in these types of leadership roles as an attending.
Learn to tie in the clinical with the practice of pathology: Make sure you know the clinical history, radiology, and previous pathology on your patient and tie them together. Get the previous slides or lab results for your patient (eg – biopsies) and compare the diagnosis with what you are seeing now. It usually matches up but occasionally you may get a surprise. Understand what’s needed for staging and the implications (eg – surgery, radiation, amputation, etc) of our diagnoses for our patients.
Double check your work and QA yourself: One of my attendings has this method and I find it useful for surgpath – “skim” your slides to get a “feel”, then look at them again more closely and fill out your diagnosis, and finally, QA yourself after you’ve written in the diagnosis to confirm and to check for anything you’ve missed.
Fix well and cut good sections: I have attendings who for cancer specimens will have you prep the specimen but fix overnight (and others who say cut fresh). Believe me, the specimen cuts better if fixed well and if you cut with skill (and a fresh sharp scalpel blade) but not force, especially with friable lesions. If you cut good sections, then you get good slides.

Above all, put the patient first and stay positive!

–Betty Chung, DO, MPH, MA is a second year resident physician at the University of Illinois Hospital and Health Sciences System in Chicago, IL.

Advice for the Incoming PGY-1 Residents

As I am repeating the motions of yesteryear when I was moving from NJ to Chicago to start my residency, except this time in reverse to return to NJ to complete the final two years of my residency, I’m reminded that it’s always good to ask for advice from those who have blazed the trail before me. And so I’d like to start with a hearty CONGRATULATIONS to the incoming pathology PGY-1 residents! This is truly a time of excitement and maybe a little apprehension of the new and unknown for you. So, I thought that I’d devote this week’s blog to pearls of wisdom I’ve picked up along the way. Fellow residents, please pipe in if you also have some advice for our incoming residents.

Enjoy your time before residency (and in some of cases, June orientation a la boot camp style) starts. Take that vacation backpacking through Europe that you always dreamed of…or volunteer overseas if you’re so inclined. Whatever you do, take some “me time” now. I know it’s easy to think that you might need to read up on your pathology but there’s time for that later. Once you start working (residency, fellowship, job), even if you are promised 4 weeks, it might be difficult to schedule that time off due to grossing schedules, your colleagues’ vacation requests, and so on. So decompress from the past 4 years of medical school and enjoy what’s left of your summer.
Hopefully, you already have done this but look for your housing way in advance, especially if you are out-of-state from where you will be a resident. Apartment websites and Craigslist are good but be careful of scams especially if they ask you send in a deposit ahead of time without seeing the place. If something sounds too good to be true, it probably is. I strongly suggest going in-person or having a trusted friend or family member check out places for you if you can’t. A great piece of advice that was given to me was to use a realtor (or more than one) who can line up places and show you around. They are usually a good source of information about where is best to live and what are reasonable prices…and you can ask them to only show you places where the landlord pays the commission. It saves time to have someone organize the appointments according to your specifications (pets, within X distance to the hospital, safety, covered utilities, parking, amenities, etc) so that you only need to show up and view the places you like and decrease the number of apartment hunting trips/calls you make. You can even search for places you like off the realtors’ website just like you’d do on Craigslist, Trulia, or Zillow especially if you want to rent or buy a condo unit. Sometimes you may need a letter of employment stating your salary and a credit report (by federal law, you can get this free q12mo from all 3 credit reporting companies through www.annualcreditreport.com but you will need to pay a small fee, about $10, to get the credit score – you can get the score free via Credit Karma but a lot of realtors will not accept it from this company so be forewarned)
Think about selling any large items you may have (such as furniture) to save on moving costs. If you really must move a lot of large items, look into moving options early because June/July is a busy moving cycle and you don’t want to be left with the less reputable companies that may be cheap but do not do a good job or very high prices or even worse, no options. You can either hire a moving company or use portable containers such as PODS, U-Haul’s U-box, or ABF U-Pack where you pack the container yourself and they drive the container to your new home and often have options to store it until you are ready to access it. Check to see if your program has an Employee Assistance Program (EAP) that can help you with relocation services and/or discounts but either way budget yourself 1-2 grand.
Get all your paperwork done ASAP. You will receive mountains of forms that need to be filled out to obtain your (temporary) medical license and allow you access to the various hospitals you will rotate at. Make it a habit now to not procrastinate because once residency starts, you will find yourself often too busy and too tired. You also do not want any delay in starting your job due to incomplete paperwork. Better to find out now if you are missing an item (eg – vaccination, physicals) and take care of it before you arrive to start.
Get to know your colleagues. Introduce yourself to everyone over email and offer to help out if they need (such as unloading their moving stuff). It’s a great way to break the ice and meet your fellow residents and start off on a friendly foot. You can even suggest some chillaxing activities to do together at the start of residency to explore your new city to get to know each other and your new home. Bonding starts from day one and it is difficult to do once the hustle and bustle of work starts and if you are in a program where you are separated to different hospitals. Also, you’ll find that your senior residents will have a lot of good advice to give and you might even find a new friend or mentor.
Join pathology advocacy organizations like the American Society of Clinical Pathology (ASCP), the College of American Pathologists (CAP), and your state/city pathology societies because they often have resident resources and this is the last time you can get free membership. Once you graduate, then you have to pay membership dues. CAP has a Residents Forum with 2 meetings per year that I found a great place to meet other residents. Both ASCP and CAP have a Resident Council and Residents Forum Executive Committee, respectively. Get involved and run for a position on either of these or on ASCP or CAP committees where you will serve with attendings. Other international organizations such as USCAP or subspecialty organizations may have dues but these are often greatly discounted for trainee members and you get discounted registration if you need to attend their conference (eg – to present a poster) so it still makes sense to join – find out if your program will pay for the dues.

Once you start residency, I won’t lie, it will be stressful. There will be times you wonder what you’ve gotten yourself into and when you may doubt if you can do all that is expected of you. But persevere and this, too, shall pass. Find yourself some good mentors – other residents, attendings, and/or ancillary staff. You may feel that you are behind and that there is so much to learn but I promise if you make sure you have a solid foundation at each step, one day you will be that senior resident who seems to know so much more than you did on day one. But for now, enjoy yourself! The studying can wait–at least until July 1^st!

–Betty Chung, DO, MPH, MA is a second year resident physician at the University of Illinois Hospital and Health Sciences System in Chicago, IL.

Halfway Through…and What’s Left to Do

I had originally started writing about a recent article I read on residents organizing as a collective bargaining unit for salary negotiations. But I’ll leave that for another day and give you a more informal blog post today.

So, for those of you who don’t know, I will be transferring to a program in my home state of NJ for personal reasons for my last two years. When I initially applied to residencies, I didn’t apply to any of the three programs in NJ because I wanted to be in a large (>4 residents/year), urban program that served a significant number of underserved minority and immigrant patients. Chicago was a familiar choice as I had attended college at The University of Chicago alongside my brother here many moons ago. It was also where I first began working with minority and immigrant community advocacy and grassroots organizing groups and my oppas (“older brothers”) and unnis (“older sisters”) then, are the leaders of these groups now.

But two years later, circumstances in my life change, priorities change, and the reasons to go home were more compelling than those to stay. It wasn’t an easy decision. My chairman and attendings here have been very supportive, especially of my extracurricular activities and research. I know that when I go to fellowship interviews, people will ask why I transferred. The reasons are innocent and legitimate enough but I do wonder if they may affect how programs will view me as a potential candidate when they hear my reasons. After all, fellowships are more competitive to obtain than residencies and any small possibly of negative perception, whether true or erroneous, can make or break whether you get those fewer positions available.

I took this week off to deal with moving tasks and my apartment is a mess of half-packed boxes. I need to get as much done before I’m back at our busiest surgpath site again next week until I leave for NJ. But the déjà vu act of packing, calling up moving companies for quotes, and selling items in order to lighten my load has put me in a contemplative mood. I realize that now I am almost halfway through this part of my journey to become a practicing pathologist.

Sometimes, I feel as if I have been weighed and measured and found wanting in terms of where I should be in AP. With my research and heavy science background, CP has always been a comfortable fit. I haven’t had any cytology rotations yet but I get to do four months in NJ. In terms of surgpath, I’m knowledgeable enough with the “bread and butter” that I see during sign-outs but not knowledgeable enough when it comes to unknowns. I know I should read more and often wonder why I don’t do as much as I could.

But now that I’ve come to this fork in my journey, moving back to NJ and thinking about applying for my first fellowship, I wonder what do I need to become the best pathologist I can with the time I have left? I don’t want to be cramming everything I should’ve learned in three years into my last year when boards studying fever hits. If anyone has some advice or anecdotes about their training to illustrate something that is working for them, please feel free to share.

And yet, even though our studies and service duties are, of course very important, how should we engage in molding our profession into the pathology of the next age? What are the most salient skills we need to acquire and how do we show the clinical care teams that are evolving within healthcare reform just where our place is within it? What are the most pressing issues for residents? Salaries, autonomy to influence our education, didactics, service duties, or clinical care? Where should we most focus our efforts?

–Betty Chung, DO, MPH, MA is a second year resident physician at the University of Illinois Hospital and Health Sciences System in Chicago, IL.

Training Towards Boards and/or Practice? Or a Little of Both?

So when I was in medical school, we all had our medical licensing boards (aka “the Steps”), at least two of them, to worry about passing in order to matriculate into residencies and to start the process for obtaining our medical licenses. It was a rite of passage. And even though many of us stressed and spent many a sleepless night in worry and study to pass them, they were not seen as insurmountable by most. The Steps were perceived as an important exam we had to take while going about the actual practice of medicine. During my second year, we only got two weeks off at the end for Step 1 study time. During my clinical years, we didn’t get any specifically designated time off to study for Step 2 unless we used our two week vacation.

And yet, when it comes to our specialty boards, the stakes feel immeasurably higher and most training programs do not set aside an uninterrupted study time period for these exams. After all, we are employees, where our absence means someone else is doing our work. While I was rotating as a medical student on elective pathology rotations and from what I’ve seen and heard since becoming a resident, many PGY-4 everywhere spend their senior year using their saved up vacation time and/or lighter CP rotations to study mainly for boards. Some are even barely seen on the rotation service and are more often seen glued to their cubicles studying or listening to boards review lectures. But what does this say for how we train our pathology residents?

Full disclosure…I am a concentrated crammer, always have been – a habit that I am still working to break but since I generally so well on standardized tests, I haven’t had the selective pressure to change as quickly as I probably should. So, I can’t imagine consistently studying for a year or two for these exams. Although I can imagine stressing over them for that long, I don’t have the attention span, memory abilities, or discipline to learn in this way. There is nothing wrong with the slow and steady study personality. But for me, I learn more by doing than by just reading or listening to lectures. And hopefully, this translates to needing to study less and not needing to feel as if I have to learn everything I should have in 3 years of residency crammed into 1 when my time comes.

But the specialty boards really seem to push our buttons, even to the point where there have been headlines of residents and fellows punished for their use of remembrances with some cases resulting in cancellation of scores. For many of those providing such remembrances to others, suspension of medical licenses have even occurred. Are we conditioned to feel that we need protected study time in order to feel confident that we will pass? Because as residents, who are no longer medical students, no such time is allotted because we need to carry out patient care.

So why do we seem to freak out so much more about our boards exams as a resident/fellow, then we did as a medical student? As a medical student, we learned most of the material for Step 1 during our basic science years. If we studied for our clinical rotations and attended clinical lectures, then we also were exposed to much of the material we would see on Steps 2 and 3. But do we learn enough while on pathology rotations to recognize most of the material we will see on our AP and CP boards? Or is it just the perception that we aren’t exposed to everything we need to be during our rotations that makes many residents spend a year or more studying for these exams?

From my experience, residency training programs are more variable than medical schools are in terms of their curriculum and exposures. So, how can we transform our training within the confines of our specific program’s idiosyncrasies to provide what we need?

–Betty Chung, DO, MPH, MA is a second year resident physician at the University of Illinois Hospital and Health Sciences System in Chicago, IL.